Basic Information
| Provider Information | |||||||||
| NPI: | 1912168857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOSWAMI | ||||||||
| FirstName: | PUJA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6622 N 91ST AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853052569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027596883 | ||||||||
| FaxNumber: | 6022243358 | ||||||||
| Practice Location | |||||||||
| Address1: | 5750 W THUNDERBIRD RD STE F680 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028437171 | ||||||||
| FaxNumber: | 6028661440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 54521 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | A126554 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 298466 | 05 | AZ | MEDICAID |